Clinical Biomechanics - Articles in Press

Gait termination strategies differ between those with and without ankle instability - Corrected Proof

Erik A. Wikstrom, Chris J. Hass — 2012-01-30

Abstract: Background: Chronic ankle instability is a common occurrence after an ankle sprain. Yet, some people (copers) possess a mechanism that limits recurrent injury and disability. During gait termination, those with chronic ankle instability exhibit altered feed-forward and feedback control but little is known about alterations in copers. Therefore, the purpose of this investigation was to determine the biomechanical control alterations present in controls, copers, and those with chronic ankle instability during planned and unplanned gait termination.Methods: Twenty subjects with chronic ankle instability, 20 copers, and 20 uninjured controls completed planned and unplanned gait termination tasks. Unplanned gait termination required subjects to stop, when cued, during randomly selected trials. Planned gait termination required intended stopping. A total of 10 trials were recorded for each condition. Normalized propulsive and braking force magnitudes and dynamic postural stability indices were calculated and compared among the groups.Findings: Normalized maximum braking forces were significantly higher in the chronic ankle instability group (Mean: 2.82 SD: 0.93N/kg), relative to copers (Mean: 2.59 SD: 0.84N/kg) and controls (Mean: 2.51 SD: 0.78N/kg). Similarly, the antero-posterior postural stability index revealed higher scores in the chronic ankle instability group (Mean: 0.15 SD: 0.03) compared to the coper (Mean: 0.14 SD: 0.02) and control group (Mean: 0.14 SD: 0.02). Copers did not differ from controls.Interpretation: The findings suggest that the ability of copers to terminate gait in a manner similar to uninjured controls may represent part of the underlying mechanism that limits recurrent injury and disability in copers.

A comparison of Anterior Cruciate Ligament graft tunnel orientation: Anatomic vs. transtibial - Corrected Proof

Michael S. Potter, Frederick W. Werner, Levi G. Sutton, Scott K. Schweizer — 2012-01-30

Abstract: Background: Recent Anterior Cruciate Ligament reconstruction techniques have emphasized reproducing the insertion sites of the native Anterior Cruciate Ligament. Anatomic techniques have shown improvements in biomechanical testing, but their superior results have not been shown clinically. The hypothesis of this study is that more oblique tunnels utilized in anatomic reconstructions cause asymmetric loading across the graft.Methods: Seven cadaver knees were tested in a knee simulator that performed a gait cycle and an anterior–posterior laxity test. Each knee underwent both reconstructions in random order utilizing the same Anterior Cruciate Ligament bone patellar tendon bone graft. Before reconstruction, the graft was split longitudinally and miniature force probes were inserted in the medial and lateral portions.Findings: During anterior–posterior laxity testing, the transtibial medial bundle averaged 74.8N compared to 87N for the anatomic. The lateral bundles averaged 146.2 and 158N respectively. Both reconstructions exhibited a similar ratio of force distribution between the bundles and there was no statistical difference. The average anterior–posterior motion for the intact knees was 10.8mm compared to 17.0mm after the Anterior Cruciate Ligament was sectioned. Anatomic reconstructions had an average of 14.0mm of laxity compared to 14.9mm for transtibial reconstructions (P<0.038).Interpretation: Greater obliquity did not lead to an increase in asymmetry of graft loading. The failure of anatomic reconstructions to show clinical improvement over transtibial reconstructions is not due to oblique tunnels causing asymmetric graft loading.

The biomechanical effects of a deepened articular cavity during dynamic motion of the wrist joint - Corrected Proof

Stefanie Erhart, Werner Schmoelz, Rohit Arora, Martin Lutz — 2012-01-30

Abstract: Background: A deepened articular cavity of the distal radius due to a metaphyseal comminution zone is associated with early osteoarthritis and reduced joint motion. As this deformity has not been investigated biomechanically, the purpose of this study was to evaluate the effects of a deepened articular cavity on contact biomechanics and motion range in a dynamic biomechanical setting.Methods: Six fresh frozen cadaver forearms were tested in a force controlled test bench during dynamic flexion and extension and intact mean contact pressure and contact area as well as range of motion were evaluated. Malunion was then simulated and intraarticular as well as motion data were obtained. Intact and malunion data were compared for the scaphoid and lunate facet and the total radial joint surface.Findings: Due to malunion simulation, cavity depth increased significantly. Motion decreased significantly to 54–69% when compared to the intact state. Malunion simulation led to a significant decrease of contact area in maximum extension for all locations (by ~50%). In maximum flexion and neutral position, contact area decrease was significant for the scaphoid fossa (by 51–54%) and the total radial joint surface (by 47–50%). Contact pressure showed a significant increase in maximum extension in the scaphoid fossa (by 129%).Interpretation: Already a small cavity increase led to significant alterations in contact biomechanics of the radiocarpal joint and to a significant range of motion decrease. This could be the biomechanical cause for degenerative changes after the investigated type of malunion. We think that restoration of the normal distal radius shape can minimize osteoarthritis risk post trauma and improve radiocarpal motion.

Range of motion of the metacarpophalangeal joint in rheumatoid patients, with and without a flexible joint replacement prosthesis, compared with normal subjects - Corrected Proof

2012-01-20

Abstract: Background: The metacarpophalangeal is commonly affected by rheumatoid arthritis. This may lead to joint replacement with a flexible prosthesis. The aims of this study were to determine the effects of rheumatoid arthritis on joint motion and to determine whether joint replacement needs to restore the full range of motion.Methods: Three-dimensional motion analysis was used to measure the range of motion of the metacarpophalangeal joint in rheumatoid patients with and without a flexible silicone arthroplasty, when performing pinch and key grips, when making a fist and when spreading the fingers. The results were compared with those from younger and older normal subjects.Findings: There appeared to be a trend for a decrease in range of motion from younger normal to older normal to rheumatoid (no prosthesis) to rheumatoid (with prosthesis) subject groups. However, statistically different (p<0.05) results were only observed for some movements (mostly involved in making a fist), in some fingers and between some subject groups. The only exception to this apparent trend was in flexion/extension when spreading the fingers into abduction.Interpretation: Making a fist is the most sensitive simple measure of range of motion in the metacarpophalangeal joint. Successful replacement of the metacarpophalangeal joint in patients with rheumatoid arthritis need not restore the normal range of motion.

Predictive equations for lumbar spine loads in load-dependent asymmetric one- and two-handed lifting activities - Corrected Proof

N. Arjmand, A. Plamondon, A. Shirazi-Adl, M. Parnianpour, C. Larivière — 2012-01-20

Abstract: Background: Asymmetric lifting activities are associated with low back pain.Methods: A finite element biomechanical model is used to estimate spinal loads during one- and two-handed asymmetric static lifting activities. Model input variables are thorax flexion angle, load magnitude as well as load sagittal and lateral positions while response variables are L4–L5 and L5–S1 disc compression and shear forces. A number of levels are considered for each input variable and all their possible combinations are introduced into the model. Robust yet user-friendly predictive equations that relate model responses to its inputs are established.Findings: Predictive equations with adequate goodness-of-fit (R2 ranged from ~94% to 99%, P≤0.001) that relate spinal loads to task (input) variables are established. Contour plots are used to identify combinations of task variable levels that yield spine loads beyond the recommended limits. The effect of uncertainties in the measurements of asymmetry-related inputs on spinal loads is studied.Interpretation: A number of issues regarding the NIOSH asymmetry multiplier are discussed and it is concluded that this multiplier should depend on the trunk posture and be defined in terms of the load vertical and horizontal positions. Due to an imprecise adjustment of the handled load magnitude this multiplier inadequately controls the biomechanical loading of the spine. Ergonomists and bioengineers, faced with the dilemma of using either complex but more accurate models on one hand or less accurate but simple models on the other hand, have hereby easy-to-use predictive equations that quantify spinal loads under various occupational tasks.

Investigation into three dimensional hip anatomy in anterior dislocation after THA. Influence of the position of the hip rotation centre - Corrected Proof

Elhadi Sariali, Shahnez Klouche, Patrick Mamoudy — 2012-01-19

Abstract: Background: The components position is a major factor under the surgeon's control in determining the risk of dislocation post total hip arthroplasty. The aim of this study was to investigate the proper three-dimensional components position including the centre of rotation in the case of anterior dislocation.Methods: Among 1764 consecutive patients who underwent total hip arthroplasty using a direct anterior approach, 27 experienced anterior dislocation. The three-dimensional hip anatomy was investigated in 12 patients who were paired with 12 patients from the same initial cohort who did not experience dislocation and also with 36 control patients with osteoarthritis. A pelvic Cartesian referential was defined to perform the acetabular analysis. The coordinates were expressed as percentages of the pelvic width, height and depth. The anteversion angles were measured.Findings: The hip centre of rotation was significantly shifted medially and posteriorly in the dislocation group when compared to the non-dislocation group and also to the control group. There was no significant difference in component angular position between the dislocation-group and the non-dislocation group. However, the stem anteversion in the dislocation group was increased in comparison to the mean natural femoral anteversion of the control group.Interpretation: A medial and posterior displacement of the hip rotation centre was found to correlate to anterior dislocation post total hip arthoplasty. These results suggest the importance of an accurate restoration of the centre of rotation, whilst avoiding an excessive acetabular reaming which may induce a medial and a posterior displacement.Level of evidence: III comparative non randomised.

Gait patterns of asymmetric ankle osteoarthritis patients - Corrected Proof

2012-01-19

Abstract: Background: In early stages, ankle osteoarthritis is often asymmetric with only partially degenerated joint surfaces. There is only limited knowledge on the effect of asymmetric ankle osteoarthritis on the patients' gait patterns. Therefore, the aim of this study was to characterize kinematic and kinetic changes compared to healthy adults.Methods: Instrumented gait analysis was performed in eight asymmetric ankle osteoarthritis patients and 15 healthy controls. Beside conventional gait analysis methods, principal component analysis was used to analyze temporal progression of the most important variables: hindfoot dorsiflexion angle and vertical ground reaction force.Findings: Asymmetric ankle osteoarthritis patients had a lower hindfoot dorsiflexion and rotation range of motion as well as reduced peak ground reaction forces and peak kinetic values. Principal component analysis revealed that for both the hindfoot dorsiflexion angle and the vertical ground reaction force those principal component vectors affecting the amplitudes had significantly lower principal component scores in patients than in controls. The use of the principal component scores for classification with a linear support vector machine resulted in a high recognition rate of 97.8% for the discrimination between the affected leg and the healthy controls.Interpretation: Patients with asymmetric ankle osteoarthritis suffer from substantial pathological kinematic and kinetic gait changes. Principal component analysis combined with a linear support vector machine could successfully be used to temporally quantify and classify asymmetric ankle osteoarthritis gait patterns. This study therefore helps to understand the pathomechanism of early stage ankle osteoarthritis from a biomechanical view.

Alterations in in vivo knee joint kinematics following a femoral nerve branch block of the vastus medialis: Implications for patellofemoral pain syndrome - Corrected Proof

Frances T. Sheehan, Bhushan S. Borotikar, Abrahm J. Behnam, Katharine E. Alter — 2012-01-16

Abstract: Background: A potential source of patellofemoral pain, one of the most common problems of the knee, is believed to be altered patellofemoral kinematics due to a force imbalance around the knee. Although no definitive etiology for this imbalance has been found, a weak vastus medialis is considered a primary factor. Therefore, this study's purpose was to determine how the loss of vastus medialis obliquus force alters three-dimensional in vivo knee joint kinematics during a volitional extension task.Methods: Eighteen asymptomatic female subjects with no history of knee pain or pathology participated in this IRB approved study. Patellofemoral and tibiofemoral kinematics were derived from velocity data acquired using dynamic cine-phase contrast MRI. The same kinematics were then acquired immediately after administering a motor branch block to the vastus medialis obliquus using 3–5ml of 1% lidocaine. A repeated measures analysis of variance was used to test the null hypothesis that the post- and pre-injection kinematics were no different.Findings: The null hypothesis was rejected for patellofemoral lateral shift (P=0.003, max change=1.8mm, standard deviation=1.7mm), tibiofemoral lateral shift (P<0.001, max change=2.1mm, standard deviation=2.9mm), and tibiofemoral external rotation (P<0.001, max change=3.7°, standard deviation=4.4°).Interpretation: The loss of vastus medialis obliquus function produced kinematic changes that mirrored the axial plane kinematics seen in individuals with patellofemoral pain, but could not account for the full extent of these changes. Thus, vastus medialis weakness is likely a major factor in, but not the sole source of, altered patellofemoral kinematics in such individuals.

Whole body kinematics and knee moments that occur during an overhead catch and landing task in sport - Corrected Proof

2012-01-13

Abstract: Background: Athletes suffering an anterior cruciate ligament injury tend to exhibit similar body postures that in sidestep cutting are associated with increased knee moments. This relationship, however, has not been investigated in landing. Catching a ball in different overhead positions may affect landing postures and knee joint moments. This study investigated these possible relationships. It was anticipated that some joint postures would be associated increased knee loads during the landing task.Methods: Twenty-five healthy male team sports athletes performed four variations of a landing task. Full body kinematics were identified at initial contact. Peak flexion, valgus and internal rotation moments at the knee, measured during early landing, were normalized to mass and height and statistically compared. Intra-participant correlations were performed between all kinematics and each moment. Mean slopes for each correlation were used to identify the existence of relationships between full body kinematics and knee joint moments.FindingsLanding after an overhead catch when the ball moved towards a player's support leg resulted in increased peak valgus moments. These increased valgus moments were correlated with increased knee flexion, hip flexion, and torso lean, as well as torso rotation towards the support leg, and foot and knee external rotation. Increased internal rotation moments were correlated with reduced hip abduction and external rotation, increased ankle inversion, knee external rotation and torso lean away from the support leg.InterpretationLearning to land with techniques that do not reflect postures associated with high knee moments may reduce an athlete's risk of non-contact anterior cruciate ligament injury.

Comparison of peak knee adduction moment and knee adduction moment impulse in distinguishing between severities of knee osteoarthritis - Corrected Proof

2012-01-13

Abstract: Background: The peak knee adduction moment is a valid proxy for medial knee joint loading. However as it only measures load at one instance of stance, knee adduction moment impulse, a measure that takes into account both the magnitude and duration of the stance phase, may provide more comprehensive information. This study directly compared the abilities of peak knee adduction moment and knee adduction moment impulse to distinguish between knee osteoarthritis severities.Methods: 169 participants with medial knee osteoarthritis completed radiographic and magnetic resonance imaging, the Western Ontario and McMaster Universities Arthritis Index to assess pain and a three-dimensional gait analysis. Participants were classified using four dichotomous classifications: Kellgren–Lawrence grading, alignment, medial tibiofemoral bone marrow lesions, and pain.Findings: When using Kellgren–Lawrence grade and alignment classifications, the area under the receiver operator curves were significantly greater for knee adduction moment impulse than for peak knee adduction moment. Based on analysis of covariance, knee adduction moment impulse was significantly different between Kellgren–Lawrence grade and alignment groups while peak knee adduction moment was not significantly different. Both peak knee adduction moment and knee adduction moment impulse distinguished between bone marrow lesion severities while neither measure was significantly different between pain severity groups.Interpretations: Findings suggest knee adduction moment impulse is more sensitive at distinguishing between disease severities and may provide more comprehensive information on medial knee joint loading. Future studies investigating biomechanics of knee osteoarthritis should include knee adduction moment impulse in conjunction with peak knee adduction moment.

Tibial rotation in anterior cruciate ligament reconstructed knees during single limb hop and drop landings - Corrected Proof

Kate E. Webster, Julian A. Feller — 2012-01-13

Abstract: Background: Alterations in knee joint kinematics have been suggested as a potential mechanism that influences the development of osteoarthritis of the knee after anterior cruciate ligament reconstruction. Whilst previous work has shown changes in internal–external tibial rotation during level walking, many patients aim to return to high impact activities following surgery. This study examined tibial rotation during single limb hop and drop landings in anterior cruciate ligament reconstructed knees compared to a control group, and also evaluated the influence of graft type (hamstring or patellar tendon).Methods: In 48 participants (17 patellar tendon graft, 18 hamstring graft and 13 controls) internal–external rotation was measured during single limb hop and drop landings in a gait laboratory at mean of 10months after surgery.Findings: There was no difference between the two graft types and both patient groups had less internal rotation when compared to the control group. For 60% of patients, internal rotation values were at least 5° less than the control group mean.Interpretation: Anterior cruciate ligament reconstructed knees with both hamstring tendon and patellar tendon grafts show altered rotational kinematic patterns during high impact dynamic load activities.

A comparative biomechanical study of a novel integrated plate spacer for stabilization of cervical spine: An in vitro human cadaveric model - Corrected Proof

Kamran Majid, Suresh Chinthakunta, Aditya Muzumdar, Saif Khalil — 2012-01-13

Abstract: Background: Integrated plate-spacer may provide adequate construct stability while potentially lowering operative time, decreasing complications, and providing less mechanical obstruction. The purpose of the current study was to compare the biomechanical stability of an anatomically profiled 2-screw integrated plate-spacer to a traditional spacer only and to a spacer and anterior cervical plate construct. In addition, the biomechanical stability of 2-screw integrated plate-spacer was compared to a commercially available 4-screw integrated plate-spacer.Methods: Two groups, each of nine cervical cadaver spines (C2–C7), were tested under pure moments of 1.5Nm. Range of motion was recorded at C5–C6 in all loading conditions (flexion, extension, lateral bending, and axial rotation) for the following constructs: 1) Intact; 2) 2-screw or 4-screw integrated plate-spacer; 3) spacer and anterior cervical plate; and 4) spacer only.Findings: All fusion constructs significantly reduced motion compared to the intact condition. Within the instrumented constructs, spacer and anterior cervical plate, 2-screw and 4-screw integrated plate-spacer resulted in reduced motion compared to the spacer only construct. No significant differences were found in motion between any of the instrumented conditions in any of the loading conditions.Interpretation: The application of integrated plate-spacer for anterior cervical discectomy and fusion is based on several factors including surgical ease-of-use, biomechanical characteristics, and surgeon preference. The study suggests that integrated plate-spacer provide biomechanical stability comparable to traditional spacer and plate constructs in the cervical spine. Clinical studies on integrated plate spacer devices are necessary to understand the performance of these devices in vivo.

The contribution of quasi-joint stiffness of the ankle joint to gait in patients with hemiparesis - Corrected Proof

2012-01-09

Abstract: Background: The role of ankle joint stiffness during gait in patients with hemiparesis has not been clarified. The purpose of this study was to determine the contribution of quasi-joint stiffness of the ankle joint to spatiotemporal and kinetic parameters regarding gait in patients with hemiparesis due to brain tumor or stroke and healthy individuals.Methods: Spatiotemporal and kinetic parameters regarding gait in twelve patients with hemiparesis due to brain tumor or stroke and nine healthy individuals were measured with a 3-dimensional motion analysis system. Quasi-joint stiffness was calculated from the slope of the linear regression of the moment–angle curve of the ankle joint during the second rocker.Findings: There was no significant difference in quasi-joint stiffness among both sides of patients and the right side of controls. Quasi-joint stiffness on the paretic side of patients with hemiparesis positively correlated with maximal ankle power (r=0.73, P<0.01) and gait speed (r=0.66, P<0.05). In contrast, quasi-joint stiffness in controls negatively correlated with maximal ankle power (r=−0.73, P<0.05) and gait speed (r=−0.76, P<0.05).Interpretation: Our findings suggested that ankle power during gait might be generated by increasing quasi-joint stiffness in patients with hemiparesis. In contrast, healthy individuals might decrease quasi-joint stiffness to avoid deceleration of forward tilt of the tibia. Our findings might be useful for selecting treatment for increased ankle stiffness due to contracture and spasticity in patients with hemiparesis.

The effect of clavicle malunion on shoulder biomechanics; A computational study - Corrected Proof

Bipin Patel, Peter A. Gustafson, James Jastifer — 2012-01-09

Abstract: Background: Clavicle malunion affects the biomechanics of the shoulder joint. The purpose of this study is to establish the abduction, flexion, and internal (medial) rotation biomechanics of the shoulder after clavicle malunion.Methods: A computational study was performed utilizing a three-dimensional, validated computational model of the upper extremity. Sequential shortening of the clavicle up to 20% was simulated. Muscle forces, moment arms, and moments were calculated for the surrounding musculature through a range of flexion, abduction, and internal rotation during the simulated shortening.Findings: Shortening of the clavicle decreases the shoulder elevation moments of the upper extremity muscles during abduction. Internal rotation moments are also decreased with shortening. Flexion moments were affected less through physiologic range of motion. The observed effects are due to a combination of changes in moment arms of the individual muscles as well as a decrease in the force generating capacity of the muscles. Additionally, shortening of the clavicle increases coronal angulation of the clavicle at the sternoclavicular joint.Interpretation: Shortening causes a decrease in the moment generating capacity as well as the total force generating capacity of the shoulder girdle muscles. The clinical significance of these computational results, which are consistent with recent clinical studies, is validation of the proposed functional deficit caused by clavicle malunion.

Functional capacity, muscle strength and falls in women with fibromyalgia - Corrected Proof

2012-01-09

Abstract: Background: Patients with fibromyalgia have difficulty with activities of daily living, they exhibit reduced muscle strength and high incidence of reported falls. The objective of this study was to evaluate the functional performance and lower limb muscle strength in women with fibromyalgia and determine the relationship between muscle strength and falls.Methods: Sixteen females with fibromyalgia and 16 healthy women participated in the study. Pain intensity, fibromyalgia impact on quality of life, physical activity level and fall prevalence were assessed. The peak torque and the rate of torque development were determined in maximal voluntary isometric contraction (hip, knee and ankle joints) using a load cell. The 30s chair stand, 8ft up and go, sit and reach, and functional reach tests were used to characterize functional performance.Findings: Women with fibromyalgia showed deficits in lower limb muscle strength, balance and agility and exhibited decreased knee extension peak torque and rate of torque development. In addition, they showed lower hip adduction and extension peak torque in comparison to the control group (P>0.05). Hip extension rate of torque development, duration of fibromyalgia symptoms, overall pain, knee pain, and fibromyalgia impact were strong predictors of the number of falls in patients with fibromyalgia (R2=0.86; P<0.05), when considered collectively.Interpretation: Women with fibromyalgia showed reduced functional performance and lower limb muscle strength, mostly explained by pain. There was a high prevalence of falls in this population, as explained by hip extensors rate of torque development, duration of fibromyalgia symptoms and pain.

Changes in patellofemoral joint contact pressures caused by vastus medialis muscle weakness - Corrected Proof

Andrew Sawatsky, Doug Bourne, Monika Horisberger, Azim Jinha, Walter Herzog — 2012-01-09

Abstract: Background: Patellofemoral joint pain is a common knee disorder, but its underlying causes remain unknown. One proposed mechanism is an imbalance in force in the knee extensor muscles. Specifically, the vastus medialis and vastus lateralis are thought to play a crucial role in proper patellar tracking, and weakness in vastus medialis is thought to lead to a lateral shift in the patella causing increased contact pressures and pain. The purpose of this study was to create an animal model of vastus medialis weakness and to test the effect of this weakness on patellofemoral contact pressures.Methods: Experiments were performed using New Zealand white rabbits (mass 4.9–7.7kg, n=12). Loading of the patellofemoral joint was produced by femoral nerve stimulation of the knee extensor muscles. Knee extensor imbalance was produced by vastus medialis ablation. Fuji pressure sensitive film was used to record contact area, shape and pressures for maximal and sub-maximal, matched-force contractions at knee angles of 30°, 60°, and 90°.Findings: Patellofemoral peak pressures, average pressures, contact areas and contact shapes were the same across all loading conditions for matched-force contractions before and after elimination of vastus medialis.Interpretation: We conclude that vastus medialis weakness does not cause changes in patellofemoral contact pressures. Since the muscular and knee joint geometry in rabbits and humans is similar, we question the idea of vastus medialis weakness as a cause of patellar mal-tracking and patellofemoral joint pain.

Importance of polyethylene thickness in total shoulder arthroplasty: A finite element analysis - Corrected Proof

Alexandre Terrier, Vittoria Brighenti, Dominique P. Pioletti, Farron Alain — 2012-01-06

Abstract: Background: Articular surfaces reconstruction is essential in total shoulder arthroplasty. Because of the limited glenoid bone support, thin glenoid component could improve anatomical reconstruction, but adverse mechanical effects might appear.Methods: With a numerical musculoskeletal shoulder model, we analysed and compared three values of thickness of a typical all-polyethylene glenoid component: 2, 4 (reference) and 6mm. A loaded movement of abduction in the scapular plane was simulated. We evaluated the humeral head translation, the muscle moment arms, the joint force, the articular contact pattern, and the polyethylene and cement stress.FindingsDecreasing polyethylene thickness from 6 to 2mm slightly increased humeral head translation and muscle moment arms. This induced a small decreased of the joint reaction force, but important increase of stress within the polyethylene and the cement mantel.InterpretationThe reference thickness of 4mm seems a good compromise to avoid stress concentration and joint stuffing.

Investigating the change in three dimensional deformity for idiopathic scoliosis using axially loaded MRI - Corrected Proof

J.P. Little, M.T. Izatt, R.D. Labrom, G.N. Askin, C.J. Adam — 2012-01-06

Abstract: Background: Adolescent idiopathic scoliosis is a complex three-dimensional deformity, involving a lateral deformity in the coronal plane and axial rotation of the vertebrae in the transverse plane. Gravitational loading plays an important biomechanical role in governing the coronal deformity, however, less is known about how they influence the axial deformity. This study investigates the change in three-dimensional deformity of a series of scoliosis patients due to compressive axial loading.Methods: Magnetic resonance imaging scans were obtained and coronal deformity (measured using the coronal Cobb angle) and axial rotations measured for a group of 18 scoliosis patients (Mean major Cobb angle was 43.4o). Each patient was scanned in an unloaded and loaded condition while compressive loads equivalent to 50% body mass were applied using a custom developed compressive device.Findings: The mean increase in major Cobb angle due to compressive loading was 7.4o (SD 3.5o). The most axially rotated vertebra was observed at the apex of the structural curve and the largest average intravertebral rotations were observed toward the limits of the coronal deformity. A level-wise comparison showed no significant difference between the average loaded and unloaded vertebral axial rotations (intra-observer error=2.56o) or intravertebral rotations at each spinal level.Interpretation: This study suggests that the biomechanical effects of axial loading primarily influence the coronal deformity, with no significant change in vertebral axial rotation or intravertebral rotation observed between the unloaded and loaded condition. However, the magnitude of changes in vertebral rotation with compressive loading may have been too small to detect given the resolution of the current technique.

Gait asymmetry of transfemoral amputees using mechanical and microprocessor-controlled prosthetic knees - Corrected Proof

Kenton R. Kaufman, Serena Frittoli, Carlo A. Frigo — 2012-01-05

Abstract: Background: Amputees walk with an asymmetrical gait, which may lead to future musculoskeletal degenerative changes. The purpose of this study was to compare the gait asymmetry of active transfemoral amputees while using a passive mechanical knee joint or a microprocessor-controlled knee joint.Methods: Objective 3D gait measurements were obtained in 15 subjects (12 men and 3 women; age 42, range 26–57). Research participants were longtime users of a mechanical prosthesis (mean 20years, range 3–36years). Joint symmetry was calculated using a novel method that includes the entire waveform throughout the gait cycle.Findings: There was no significant difference in hip, knee and ankle kinematics symmetry when using the different knee prostheses. In contrast, the results demonstrated a significant improvement in lower extremity joint kinetics symmetry when using the microprocessor-controlled knee.Interpretation: Use of the microprocessor-controlled knee joint resulted in improved gait symmetry. These improvements may lead to a reduction in the degenerative musculoskeletal changes often experienced by amputees.

Effective lubrication of articular cartilage by an amphiphilic hyaluronic acid derivative - Corrected Proof

Antonella Schiavinato, Robert A. Whiteside — 2012-01-04

Abstract: Background: Intra-articular injection of hyaluronic acid based therapies is gaining popularity as a treatment option for non-operative management of patients with symptomatic osteoarthritis. Although there is an abundance of evidence for both biological and mechanical mechanisms of joint protection by hyaluronic acid, one clear intention of viscosupplementation is to reduce friction and wear by providing an extrinsic lubricant. We tested the in vitro friction response of a novel hyaluronic acid derivative that presents amphiphilic features to promote adhesion to the cartilage surface and thereby improve cartilage lubrication.Methods: Migrating Contact Area and Static Contact Area friction tests were conducted on bovine articular cartilage to assess the efficacy of two lubricants, a chemically modified amphiphilic hyaluronic acid and synovial fluid from a healthy joint, as well as a phosphate buffered saline negative control.Findings: No differences in lubrication (P=0.34) were evident between the three test articles during the Migrating Contact Area test, which represents articulation of healthy articular cartilage.The modified hyaluronic acid presented an equilibrium friction coefficient 2.8 times less than that of the synovial fluid (P≤0.0005) and five times less than that of the PBS control (P≤0.0001) during the Static Contact Area test, representing a mixed lubrication condition.Interpretation: The present study demonstrated that a chemically modified amphiphilic hyaluronic acid can provide equivalent lubrication to synovial fluid during articulation of loaded healthy articular cartilage and can provide superior lubrication as indicated by a lower coefficient of friction than synovial fluid under loading conditions potentially associated with cartilage wear.

Comparison of shoulder load during power-assisted and purely hand-rim wheelchair propulsion - Corrected Proof

2011-12-30

Abstract: Background: Repetitive forces and moments are among the work requirements of hand-rim wheelchair propulsion that are related to shoulder injuries. No previous research has been published about the influence of power-assisted wheelchair propulsion on these work requirements. The purpose of our study was therefore to determine the influence of power-assisted propulsion on shoulder biomechanics and muscle activation patterns. We also explored the theoretical framework for the effectiveness of power-assisted propulsion in preventing shoulder injuries by decreasing the work requirements of hand-rim wheelchair propulsion.Methods: Nine non-wheelchair users propelled a hand-rim wheelchair on a treadmill at 0.9m/s. Shoulder biomechanics, and muscle activation patterns, were compared between propulsion with and without power-assist.Findings: Propulsion frequency did not differ significantly between the two conditions (Wilcoxon Signed Rank test/significance level/effect size:4/.314/−.34). During power-assisted propulsion we found significantly decreased maximum shoulder flexion and internal rotation angles (1/.015/−.81 and0/.008/−.89) and decreased peak force on the rim (0/.008/−.89). This resulted in decreased shoulder flexion, adduction and internal rotation moments (2/.021/−.77; 0/.008/−.89 and1/.011/−.85) and decreased forces at the shoulder in the posterior, superior and lateral directions (2/.021/−.77; 2/.008/−.89 and2/.024/−.75). Muscle activation in the pectoralis major, posterior deltoid and triceps brachii was also decreased (2/.038/−.69; 1/.015/−.81 and 1/.021/−.77).Interpretation: Power-assist influenced the work requirements of hand-rim wheelchair propulsion by healthy subjects. It was primarily the kinetics at rim and shoulder which were influenced by power-assisted propulsion. Additional research with actual hand-rim wheelchair users is required before extrapolation to routine clinical practice.

Segment choice and cup stability influence wear measurements using radiostereometric analysis: A radiostereometric study comparing wear measured by markers in the polyethylene with markers in the periacetabular bone - Corrected Proof

Einar Lindalen, Lars Nordsletten, Stephan M. Röhrl — 2011-12-26

Abstract: Background: Radiostereometry is a well documented method to measure the polyethylene wear after total hip replacements. Wear is measured according to the point motion of the head center in relation to the polyethylene as the reference segment. Increasing head sizes and new cup materials may diminish visibility of markers deteriorating the segment and leading to study drop outs. Alternatively markers in the periacetabular bone may be easier to detect rendering this segment more stable. Our aim was to compare wear measurements against the cup, the acetabuluar bone and a calculated wear estimation including cup migration.Methods: A prospective randomized controlled trial comparing reverse hybrid with cemented total hip replacement was conducted. 31 patients had tantalum markers in the polyethylene and in the periacetabular bone making it possible to measure wear using both as reference segments. We used a uniplanar radiostereometric technique.Findings: Wear in the y-axis was overestimated by 53% when markers in the periacetabular bone were used (P<0.001). Proximal wear was 0.34mm (95% CI of mean: 0.29–0.38) when using the polyethylene as the reference and 0.52mm (95% CI of mean: 0.38–0.65) using the acetabular bone. Migration of the cup seemed to influence the wear calculations, overestimating wear when markers in the periacetabular bone were used as the reference segment.Interpretation: Wear measured with periacatebular bone markers is influenced by cup migration, overestimating wear measurements. We therefore recommend not using the acetabular bone as the reference segment.

Challenges - Corrected Proof

Kim Burton, Paul Brinckmann — 2011-12-23

Regular readers of Clinical Biomechanics will be a little surprised to see an editorial. By and large, we feel our readers prefer to expand their knowledge of biomechanics than read the musings of the editorial team. However, once in a while we make a change to the journal, such as the way it is structured. On those occasions we think it appropriate to publish an explanation to our readers.

Effects of the index finger position and force production on the flexor digitorum superficialis moment arms at the metacarpophalangeal joints — a magnetic resonance imaging study - Corrected Proof

Joel R. Martin, Mark L. Latash, Vladimir M. Zatsiorsky — 2011-12-22

Abstract: Background: The purpose of this study was to use magnetic resonance imaging to measure the moment arm of the flexor digitorum superficialis tendon about the metacarpophalangeal joint of the index, middle, ring, and little fingers when the position and force production level of the index finger was altered. A secondary goal was to create regression models using anthropometric data to predict moment arms of the flexor digitorum superficialis about the metacarpophalangeal joint of each finger.Methods: The hands of subjects were scanned using a 3.0T magnetic resonance imaging scanner. The metacarpophalangeal joint of the index finger was placed in: flexion, neutral, and extension. For each joint configuration subjects produced no active force (passive condition) and exerted a flexion force to resist a load at the fingertip (active condition).Results: The following was found: (1) The moment arm of the flexor digitorum superficialis at the metacarpophalangeal joint of the index finger (a) increased with the joint flexion and stayed unchanged with finger extension; and (b) decreased with the increase of force at the neutral and extended finger postures and did not change at the flexed posture. (2) The moment arms of the flexor digitorum superficialis tendon of the middle, ring, and little fingers (a) did not change when the index metacarpophalangeal joint position changed (P>0.20); and (b) The moment arms of the middle and little fingers increased when the index finger actively produced force at the flexed metacarpophalangeal joint posture. (4) The moment arms showed a high correlation with anthropometric measurements.Interpretation: Moment arms of the flexor digitorum superficialis change due to both changes in joint angle and muscle activation; they scale with various anthropometric measures.

Describing the active region boundary of EMG-assisted biomechanical models of the low back - Corrected Proof

Xiaopeng Ning, Sangeun Jin, Gary A. Mirka — 2011-12-15

Abstract: Background: Electromyography-assisted (EMG-assisted) biomechanical models are used to characterize the muscle and joint reaction forces in the lumbar region. However, during a full-range trunk flexion, there is a transition of extension moment from the trunk extensor muscles to the passive tissues of the low back, indicating that the empirical EMG data used to drive these EMG-assisted models becomes less correlated with the extensor moment. The objectives of this study were to establish the trunk flexion angles at which the passive tissues generate substantial trunk extension moment and to document how these angles change with asymmetry.Methods: Participants performed controlled trunk flexion–extension motions in three asymmetric postures. The trunk kinematics data and the electromyographic activity from L3- and L4-level paraspinals and rectus abdominis were captured. The time-dependent net internal active moment (from an EMG-assisted model) and the net external moment were calculated. The trunk and lumbar angles at which the net internal active moment was less than 70% of the external moment were found.Findings: The trunk flexion angle at which the net internal moment reaches the stated criteria varied as a function of asymmetry of trunk flexion motion with the sagittally symmetric case providing the deepest flexion angle of 38° (asymmetry 15°: 33°; asymmetry 30°: 26°).Interpretation: These results indicate that EMG-assisted biomechanical models need to consider the role of passive tissues at trunk flexion angles significantly less than previously thought and these flexion angles vary as a function of the asymmetry and direction of motion.

Comparison of elastic versus rigid suture material for peripheral sutures in tendon repair - Corrected Proof

Kenji Nozaki, Ryuji Mori, Koji Ryoke, Yuji Uchio — 2011-12-15

Abstract: Background: For secure tendon repair, while core suture materials have been previously investigated, the optimum material for peripheral sutures remains unclear.Methods: Transected bovine gastrocnemius tendons were repaired by 2-strand side-locking loop technique using no.2 braided polyblend polyethylene thread for the core suture. Then, 8-strand peripheral cross-stitches were added using either 2–0 rigid sutures (braided polyblend polyethylene) or USP 2-0-sized elastic sutures (nylon). The holding area of each peripheral suture was set at either 3×1mm (shallow holding) or 6×2mm (deep holding). Therefore, 4 groups were compared (the shallow-rigid, deep-rigid, shallow-elastic, and deep-elastic groups). The gap formation, ultimate tensile strength, and suture migration state were measured after 500 cyclic loadings (from 10 to 200N).Methods: The shallow-rigid group had inferior outcomes compared to the other groups. Although the deep-rigid group had the smallest gap and highest ultimate strength, all peripheral sutures had failure prior to core suture rupture. The two elastic groups showed no significant differences, irrespective of the size of the holding area. Suture migration did not occur in the two elastic groups until the ultimate strength was reached and the core suture ruptured.Interpretation: Depending on the suturing method, rigid suture material may not be appropriate for peripheral sutures, when accompanying rigid core suture material. If peripheral sutures can be made with accurate deep holding, rigid suture material will provide favorable outcome. However, in other cases, elastic suture material is considered best for supporting a rigid core suture, as elasticity is another important factor for peripheral sutures.

Use of MRI for volume estimation of tibialis posterior and plantar intrinsic foot muscles in healthy and chronic plantar fasciitis limbs - Corrected Proof

Ryan Chang, Jane A. Kent-Braun, Joseph Hamill — 2011-12-14

Abstract: Background: Due to complexity of the plantar intrinsic foot muscles, little is known about their muscle architecture in vivo. Chronic plantar fasciitis may be accompanied by muscle atrophy of plantar intrinsic foot muscles and tibialis posterior compromising the dynamic support of the foot prolonging the injury. Magnetic resonance images of the foot may be digitized to quantify muscle architecture. The first purpose of this study was to estimate in vivo the volume and distribution of healthy plantar intrinsic foot muscles. The second purpose was to determine whether chronic plantar fasciitis is accompanied by atrophy of plantar intrinsic foot muscles and tibialis posterior.Methods: Magnetic resonance images were taken bilaterally in eight subjects with unilateral plantar fasciitis. Muscle perimeters were digitally outlined and muscle signal intensity thresholds were determined for each image for volume computation.Findings: The mean volume of contractile tissue in healthy plantar intrinsic foot muscles was 113.3cm3. Forefoot volumes of plantar fasciitis plantar intrinsic foot muscles were 5.2% smaller than healthy feet (P=0.03, ES=0.26), but rearfoot (P=0.26, ES=0.08) and total foot volumes (P=0.07) were similar. No differences were observed in tibialis posterior size.Interpretations: While the total volume of plantar intrinsic foot muscles was similar in healthy and plantar fasciitis feet, atrophy of the forefoot plantar intrinsic foot muscles may contribute to plantar fasciitis by destabilizing the medial longitudinal arch. These results suggest that magnetic resonance imaging measures may be useful in understanding the etiology and rehabilitation of chronic plantar fasciitis.

An ex vivo biomechanical comparison of a novel vertebral compression fracture treatment system to kyphoplasty - Corrected Proof

2011-12-12

Abstract: Background: Vertebral compression fracture repair aims to relieve pain and improve function by restoring vertebral structure and biomechanics, but is still associated with risks arising from polymethylmethacrylate cement extravasation. The Kiva® Vertebral Compression Fracture Treatment System, a stacked coil implant made of polyetheretherketone and delivered over a guide-wire, is a novel device designed to provide height restoration and mechanical stabilization, while improving cement containment and minimizing disruption of cancellous bone. The objective of this study was to determine whether the Kiva system is as effective as balloon kyphoplasty at restoring mechanical properties in osteoporotic vertebral compression fractures.Methods: Wedge fractures were created in the middle vertebra of fourteen osteoporotic three-vertebra spine segments and then repaired with either the Kiva or kyphoplasty procedure. Height, stiffness and displacement under compression of the spine segments were measured for four conditions: intact, fractured, augmented, and post-cyclic eccentric loading (50,000cycles, 200–500N, 30mm anterior lever arm).Findings: No significant differences were seen between the two procedures for height restoration, stiffness at high or low loads, or displacement under compression. However, the Kiva System required an average of 66% less cement than kyphoplasty to achieve these outcomes (mean 2.6 (SD 0.4) mL v. mean 7.5 (SD 0.8) mL 0; P<0.01). Extravasations and excessive posterior cement flow were also significantly lower with Kiva (0/7 v. 4/7; P<.05).Interpretation: Kiva exhibits similar biomechanical performance to balloon kyphoplasty, but may reduce the risk of extravasation through the containment mechanism of the implant design and by reducing cement volume.

Tibial rotation during pivoting in anterior cruciate ligament reconstructed knees using a single bundle technique - Corrected Proof

Kate E. Webster, Simon E. Palazzolo, Jodie A. McClelland, Julian A. Feller — 2011-12-12

Abstract: Background: Anterior cruciate ligament reconstruction does not necessarily restore normal knee movement. Increased tibial rotation has previously been noted during pivoting activities and may be due to the orientation of the anterior cruciate ligament graft associated with traditional single bundle reconstruction techniques. Recent research has shown that it is possible to limit rotation during level walking using a single bundle anterior cruciate ligament reconstruction. This study evaluated rotational knee kinematics during a pivot task in a group of patients who had undergone anterior cruciate ligament reconstruction using a single bundle technique and compared the findings to a normal control group.Methods: In 27 anterior cruciate ligament reconstruction and 25 control participants, internal–external rotation was measured during a descend stairs and pivot task in a gait laboratory.Findings: Results showed that the anterior cruciate ligament reconstruction patients had less internal tibial rotation (for both range of rotation and maximum rotation) than the control participants (effect size=0.7).Interpretation: These results suggest that it is possible to limit rotation after anterior cruciate ligament reconstruction using a single bundle technique, even during a pivoting movement that places a high rotational load at the knee joint. The positioning of the femoral tunnel in a more anatomical position may be responsible for the reduced tibial rotation.

Determinants of co-contraction during walking before and after arthroplasty for knee osteoarthritis - Corrected Proof

2011-12-08

Abstract: Background: Knee osteoarthritis patients co-contract in knee-related muscle pairs during walking. The determinants of this co-contraction remain insufficiently clear.Methods: A heterogeneous group of 14 patients was measured before and one year after knee arthroplasty, and compared to 12 healthy peers and 15 young subjects, measured once. Participants walked on a treadmill at several imposed speeds. Bilateral activity of six muscles was registered electromyographically, and co-contraction time was calculated as percentage of stride cycle time. Local dynamic stability and variability of sagittal plane knee movements were determined. The surgeon's assessment of alignment was used. Pre-operatively, multivariate regressions on co-contraction time were used to identify determinants of co-contraction. Post-operatively it was assessed if predictor variables had changed in the same direction as co-contraction time.Findings: Patients co-contracted longer than controls, but post-operatively, differences with the healthy peers were no longer significant. Varus alignment predicted co-contraction time. No patient had post-operative varus alignment. The patients' unaffected legs were more unstable, and instability predicted co-contraction time in both legs. Post-operatively, stability normalised. Longer unaffected side co-contraction time was associated with reduced affected side kinematic variability. Post-operatively, kinematic variability had further decreased.Interpretations: Varus alignment and instability are determinants of co-contraction. The benefits of co-contraction in varus alignment require further study. Co-contraction probably increases local dynamic stability, which does not necessarily decrease the risk of falling. Unaffected side co-contraction contributed to decreasing affected side variability, but other mechanisms than co-contraction may also have played a role in decreasing variability.

3D intersegmental knee loading in below-knee amputees across steady-state walking speeds - Corrected Proof

Nicholas P. Fey, Richard R. Neptune — 2011-12-06

Abstract: Background: Unilateral below-knee amputees often develop comorbidities that include knee joint disorders (e.g., intact leg knee osteoarthritis), with the mechanisms leading to these comorbidities being poorly understood. Mechanical knee loading of non-amputees has been associated with joint disorders and shown to be influenced by walking speed. However, the relationships between amputee knee loading and speed have not been identified. This study examined three-dimensional mechanical knee loading of amputees across a wide range of steady-state walking speeds.Methods: Fourteen amputees and 10 non-amputee control subjects were analyzed at four overground walking speeds. At each speed, intersegmental joint moment and force impulses (i.e., time-integrals over the stance phase) were compared between the control, intact and residual knees using repeated-measures ANOVAs.Findings: There were no differences in joint force impulses between the intact and control knees. The intact knee abduction moment impulse was lower than the non-amputees at 0.6 and 0.9m/s. The intact knee flexion moment impulses at 0.6, 1.2 and 1.5m/s and knee external rotation moment impulses at all speeds were greater than the residual knee. The residual knee extension moment and posterior force impulses were insensitive to speed increases, while these quantities increased in intact and control knees.Interpretation: These results suggest the intact knees of asymptomatic and relatively new amputees are not overloaded during walking compared to non-amputees. Increased knee loads may develop in response to prolonged prosthesis usage or joint disorder onset. Further study is needed to determine if the identified bilateral loading asymmetries across speeds lead to diminished knee joint health.

Femoral bone strains during antegrade nailing: A comparison of two entry points with identical nails using finite element analysis - Corrected Proof

2011-12-05

Abstract: Background: Antegrade femoral nailing has become the standard treatment for diaphyseal femoral shaft fractures. Concerns linger that improper location of the nail entry point may lead to iatrogenic fracture and further complications. This study used finite element analysis to compare the strain magnitude and distribution resulting from each of two entry points in the proximal femur during antegrade nailing.Methods: A finite element model was created from a CT scan of a 37year old male femur and of a standard antegrade nail. Using implicit time-stepping, the nail was inserted through piriformis and trochanteric entry points and strain was computed at 9 anatomic locations.Findings: The strain levels were higher overall when inserting a nail through the trochanteric starting point. The highest strain occurred immediately medial and lateral to the trochanteric entry point. The posterior greater trochanter also showed very high strain levels during nail insertion. All strain values for nail insertion through the piriformis entry point were less than 2000μm/m.Interpretation: The trochanteric entry will have a much greater potential of iatrogenic fracture of the proximal femur during insertion of a nail. Strains with this entry point exceed the yield level of bone and the repeated loading with the progression of the nail could cause fissures or fractures. Caution should be taken during insertion of an antegrade nail when utilizing a lateral trochanteric starting point secondary to an increased risk of trochanteric fracture and lateral cortex fracture.

Passive cervical spine flexion: The effect of age and gender - Corrected Proof

2011-12-02

Abstract: Background: Previous studies reported passive cervical range of motion under unknown loading conditions or with minimal detail of subject positioning. Additionally, such studies have not quantitatively ensured the absence of active muscle during passive measurements. For the purpose of validating biomechanical models the loading condition, initial position, and muscle activation must be clearly defined. A method is needed to quantify the passive range of motion properties of the cervical spine under controlled loading conditions, particularly in the pediatric population where normative clinical and model validation data is limited.Methods: Healthy female pediatric (6–12years; n=10), male pediatric (6–12years; n=9), female adult (21–40years; n=10), and male adult (20–36years; n=9) volunteers were enrolled. Subjects with restrained torsos and lower extremities were exposed to a maximum 1g inertial load in the posterior–anterior direction, such that the head–neck complex flexed when subjects relaxed their neck musculature. Surface electromyography monitored the level of muscle relaxation. A multi-camera 3-D target tracking system captured passive neck flexion angle of the head relative to the thoracic spine. General estimating equations detected statistical differences across age and gender.Findings: Passive cervical spine flexion equaled 111.0° (SD 8.0°) for pediatric females, 102.8° (SD 7.8°) for adult females, 103.8° (SD 12.7°) for pediatric males, and 93.7° (SD 9.9°) for adult males. Passive neck flexion significantly decreased with age in both genders (P<0.01). Females exhibited significantly greater flexion than males (P<0.01).Interpretation: This study contributes normative data for clinical use, biomechanical modeling, and injury prevention tool development.

Relationship between knee kinetics during jumping tasks and knee articular cartilage MRI T1rho and T2 relaxation times - Corrected Proof

2011-11-24

Abstract: Background: Articular cartilage of young healthy individuals is dynamic and responsive to loading behaviors. The purpose of this study was to evaluate the relationship of cartilage T1ρ and T2 relaxation times with loading kinetics during jumping tasks in healthy young individuals.Methods: Fourteen healthy subjects underwent: 1) motion analysis while performing a unilateral hopping task and bilateral drop jumping task; and 2) quantitative imaging using a 3 Tesla MRI for T1ρ and T2 relaxation time analysis. Three dimensional net joint moments and angular impulse was calculated using standard inverse dynamics equations. Average T1ρ and T2 relaxation times and medial-lateral ratios for each were calculated. Multiple regression was used to identify predictors of cartilage relaxation times.Findings: Average knee flexion moment during hopping was observed to best predict overall T1ρ (R2=.185) and T2 (R2=.154) values. Peak knee adduction moment during a drop jump was the best predictor of the T1ρ medial-lateral ratio (R2=.220). The T2 medial-lateral ratio was best predicted by average internal rotation moment during the drop jump (R2=.174).Interpretation: These data suggest that loads across the knee may affect the biochemistry of the cartilage. In young healthy individuals, higher flexion moments were associated with decreased T1ρ and T2 values, suggesting a potentially beneficial effect. The medial-to-lateral ratio of T1ρ and T2 times appears to be related to the frontal and transverse plane joint mechanics. These data offer promising findings of potentially modifiable parameters associated with cartilage composition.

Postural control is altered in patients with ankylosing spondylitis - Corrected Proof

Martin E. Vergara, Finbar D. O'Shea, Robert D. Inman, William H. Gage — 2011-11-23

Abstract: Background: Ankylosing spondylitis is a chronic inflammatory disorder that can lead to increased axial and peripheral joint stiffness, impairing joint mobility. Impaired axial mobility due to vertebral ankylosis may result in changes in standing postural control. Little research has addressed changes in standing postural control in the ankylosing spondylitis population, nor how these issues might affect clinical understanding and treatment.Methods: Sixteen ankylosing spondylitis patients, and 17 healthy controls participated. Each individual completed two 120-second quiet standing trials with eyes open and eyes closed, while standing upon two force platforms. Net center of pressure displacement and mean power frequency in the frontal and sagittal planes were calculated. A Spearman's rank correlation analysis was performed between net center of pressure measures and several clinical measures of disease activity.Findings: Frontal plane net center of pressure displacement and frequency content, and sagittal plane net center of pressure displacement were significantly greater within the ankylosing spondylitis patient group. Ankylosing spondylitis patients demonstrated a significant increase in frontal plane net center of pressure displacement in the eyes-closed condition. Net center of pressure displacement and frequency were significantly correlated to the Bath Ankylosing Spondylitis Functional Index, and individual components of the Bath Ankylosing Spondylitis Metrology Index.Interpretation: Quiet standing postural control was altered particularly so in the frontal plane in patients with ankylosing spondylitis, which may be associated with increased fall risk. Posturographic measures of postural control may serve as valuable clinical tools for the monitoring of disease progression and disease status in ankylosing spondylitis.

Discriminating between maximal and feigned isokinetic knee musculature performance using waveform similarity measures - Corrected Proof

2011-11-17

Abstract: Background: Muscle strength test outcomes may aid in determination of impairment or disability rating following injury. In such settings, verification of participant effort during testing is imperative. This investigation explored the utilization of within-set moment waveform similarity measures, namely cross correlation and percent root mean square difference scores, to develop decision rules for discriminating between maximal and feigned efforts during isokinetic testing of the knee joint musculature.Methods: A mixed-gender sample of 46 participants performed non-reciprocal sets of maximal or feigned knee extension and flexion concentric and eccentric efforts at testing velocities of 30°s–1 and 120°s–1. Logistic regression and Monte Carlo simulations were used to derive decision rules for differentiating between the two effort types.Findings: Employing cutoff scores corresponding to 100% specificity; sensitivities of the knee extensor's velocity-specific decision rules were 92.4% and 84.8%, respectively. The velocity-specific knee flexor's test sensitivities were 56.5% and 46.7%.Interpretation: Utilizing the proposed decision rules, substantiating maximal effort performance of the knee extensors may be possible using this specific testing protocol. However, the proposed methods are limited in their ability to verify performance of maximal knee flexor efforts.

Full and surface tibial cementation in total knee arthroplasty: A biomechanical investigation of stress distribution and remodeling in the tibia - Corrected Proof

2011-11-14

Abstract: Background: Aseptic tibial component loosening remains a major cause of total knee arthroplasty failure. The cementation technique used to achieve fixation may play a major role in loosening. Despite this, the optimum technique remains unanswered. This study aims to investigate stress and strain distributions in the proximal tibia for full cementation and surface cementation of the Genesis II tibial component.Methods: Principal cortical bone strains were measured experimentally in intact, surface cemented and fully cemented synthetic tibiae using strain gauges. Both axial and 15° flexion loading were considered. Finite element models were used to assess both cortical and cancellous bone stresses and strains. Using a bone remodeling algorithm potential sites of bone formation and resorption were identified post-implantation.Findings: Principal cortical bone strain results demonstrate strong correlations between the experimental and finite element analyses (R2≥0.81, RMSE(%)≤17.5%). Higher cortical strains are measured for surface cementation, as full cementation creates a stiffer proximal tibial structure. Simulations reveal that both cementation techniques result in lower cancellous stresses under the baseplate compared to the intact tibia, with greater reductions being computed for full cementation. The surface cementation model displays the closest cancellous stress distribution to the intact model. In addition, bone remodeling simulations predict more extensive bone resorption under the baseplate for full cementation (43%) than for surface cementation (29%).Interpretation: Full cementation results in greater stress reduction under the tibial baseplate than surface cementation, suggesting that surface cementation will result in less proximal bone resorption, thus reducing the possibility of aseptic loosening.

Exposure to a workday environment results in an increase in anterior tilting of the scapula in dental hygienists with greater employment experience - Corrected Proof

Luke Ettinger, Philip McClure, Laurel Kincl, Andrew Karduna — 2011-11-11

Abstract: Background: Dental hygienists suffer a high incidence of shoulder pathology that seems to increase with job longevity. It has been hypothesized that occupational injuries could be due to local muscle fatigue caused by repetitive low level work and awkward and constrained working postures. In the laboratory, scapular kinematics can be temporarily altered using fatiguing protocols. It is unknown whether or not workday fatigue causes changes to scapular kinematics. The aim of this study was to examine if changes in scapular tilt and rotation occurs after a workday in dental hygienists.Methods: The pre and post workday scapular kinematics were recorded from dental hygienists using an electromagnetic tracking system. All data were recorded within the place of employment of the dental hygienist.Results: Following the workday, there was significantly more scapular anterior tilt in dental hygienists (P<0.05); however, no changes were found for upward or internal rotation. Greater kinematic differences were found for hygienists with greater job longevity.Interpretation: The increase in scapular anterior tilting could be due to post workday fatigue. Anterior tilting of the scapula may have an influence on the development of subacromial impingement syndrome. Hygienists with greater duration of work experience may be at greater risk for developing shoulder injuries as they have more anterior tilting of the scapula post workday.

Simulated effect of reaction force redirection on the upper extremity mechanical demand imposed during manual wheelchair propulsion - Corrected Proof

Joseph M. Munaretto, Jill L. McNitt-Gray, Henryk Flashner, Philip S. Requejo — 2011-11-10

Abstract: Background: Manual wheelchair propulsion is associated with overuse injuries of the shoulder. Reaction force redirection relative to upper extremity segments was hypothesized as a means to redistribute mechanical load imposed on the upper extremity without decrements in wheelchair propulsion performance.Methods: Two individuals performed wheelchair propulsion under simulated inclined (graded) conditions using self-selected control strategies. Upper extremity kinematics and reaction forces applied to the wheel were quantified and used as input into an experiment-based multi-link inverse dynamics model that incorporates participant-specific experimental results. Reaction force direction was systematically modified to determine the mechanical demand imposed on the upper extremity (elbow and shoulder net joint moments and net joint forces) during wheelchair propulsion. Results were presented as solution spaces to examine the upper extremity load distribution characteristics within and between participants across a range of reaction force directions.Findings: Redirection of the reaction force relative to the upper extremity segments provides multiple solutions for redistributing mechanical demand across the elbow and shoulder without decrements in manual wheelchair propulsion performance. The distribution of load across RF directions was participant specific and was found to vary with time during the push phase.Interpretation: Solution spaces provide a mechanical basis for individualized interventions that aim to maintain function and redistribute load away from structures at risk for injury (e.g. reduce demand imposed on shoulder flexors (reduce shoulder net joint moment) or reduce potential for impingement (reduce shoulder net joint force).

Are the kinematics of the knee joint altered during the loading response phase of gait in individuals with concurrent knee osteoarthritis and complaints of joint instability? A dynamic stereo X-ray study - Corrected Proof

2011-11-10

Abstract: Background: Joint instability has been suggested as a risk factor for knee osteoarthritis and a cause of significant functional decline in those with symptomatic disease. However, the relationship between altered knee joint mechanics and self-reports of instability in individuals with knee osteoarthritis remains unclear.Methods: Fourteen subjects with knee osteoarthritis and complaints of joint instability and 12 control volunteers with no history of knee disease were recruited for this study. Dynamic stereo X-ray technology was used to assess the three-dimensional kinematics of the knee joint during the loading response phase of gait.Findings: Individuals with concurrent knee osteoarthritis and joint instability demonstrated significantly reduced flexion and internal/external rotation knee motion excursions during the loading response phase of gait (P<0.01), while the total abduction/adduction range of motion was increased (P<0.05). In addition, the coronal and transverse plane alignment of the knee joint at initial contact was significantly different (P<0.05) for individuals with concurrent knee osteoarthritis and joint instability. However, the anteroposterior and mediolateral tibiofemoral joint positions at initial contact and the corresponding total joint translations were similar between groups during the loading phase of gait.Interpretations: The rotational patterns of tibiofemoral joint motion and joint alignments reported for individuals with concurrent knee osteoarthritis and joint instability are consistent with those previously established for individuals with knee osteoarthritis. Furthermore, the findings of similar translatory tibiofemoral motion between groups suggest that self-reports of episodic joint instability in individuals with knee osteoarthritis may not necessarily be associated with adaptive alterations in joint arthrokinematics.

Cortical bone drilling and thermal osteonecrosis - Corrected Proof

2011-11-10

Abstract: Background: Bone drilling is a common step in operative fracture treatment and reconstructive surgery. During drilling elevated bone temperature is generated. Temperatures above 47°C cause thermal osteonecrosis which contributes to screw loosening and subsequently implant failures and refractures.Methods: The current literature on bone drilling and thermal osteonecrosis is reviewed. The methodologies involved in the experimental and clinical studies are described and compared.Findings: Areas which require further investigation are highlighted and the potential use of more precise experimental setup and future technologies are addressed.Interpretation: Important drill and drilling parameters that could cause increase in bone temperature and hence thermal osteonecrosis are reviewed and discussed: drilling speed, drill feed rate, cooling, drill diameter, drill point angle, drill material and wearing, drilling depth, pre-drilling, drill geometry and bone cortical thickness. Experimental methods of temperature measurement during bone drilling are defined and thermal osteonecrosis is discussed with its pathophysiology, significance in bone surgery and methods for its minimization.

Biomechanical analysis of pedicle screw thread differential design in an osteoporotic cadaver model - Corrected Proof

2011-11-09

Abstract: Background: Pedicle screw fixation, the standard surgical care for posterior stabilization in the thoraco-lumbar spine has a high rate of failure in osteoporotic individuals. Screw design factors and insertion techniques have been shown to influence the biomechanical performance of pedicle screws. Our objective was to investigate the biomechanical characteristics of pedicle screw fixation in osteoporotic bone by comparing standard screws with newly designed differential crest thickness dual lead screws.Methods: An in-vitro spinal-level paired factorial study design was used to examine thoraco-lumbar spine biomechanical outcomes for differential pedicle screw thread designs. Six cadaveric human spines (T8-L5) were tested for six groups (n=20) consisting of 2 different crest thickness and 3 different insertion techniques. Bone mineral density was assessed and peak insertion torque measured while placing one screw of new design and control on the contralateral side. Screw pullout properties were measured from classical American Society for Testing and Materials protocols.Findings: The screws designed specifically for osteoporotic bone showed significantly larger insertion torque compared with the standard screw design irrespective of insertion technique. Much of the variability in pullout failure and stiffness was explained by bone mineral density. The osteoporotic screws of different crest thickness were statistically similar to each other in all outcome measures.Interpretation: Compared with standard pedicle screws, the dual lead osteoporotic-specific pedicle screws demonstrated significantly larger insertion torques and similar pullout properties. Non-significant increased biomechanical strength was observed for thin crest compared to thick crest dual lead pedicle screws indicating their enhanced purchase in osteoporotic bone.

Proximal and distal kinematics in female runners with patellofemoral pain - Corrected Proof

2011-11-09

Abstract: Background: Female runners have a high incidence of developing patellofemoral pain. Abnormal mechanics are thought to be an important contributing factor to patellofemoral pain. However, the contribution of abnormal trunk, hip, and foot mechanics to the development of patellofemoral pain within this cohort remains elusive. Therefore the aim of this study was to determine if significant differences during running exist in hip, trunk and foot kinematics between females with and without patellofemoral pain.Methods: 32 female runners (16 patellofemoral pain, 16 healthy control) participated in this study. All individuals underwent an instrumented gait analysis. Between-group comparisons were made for hip adduction, hip internal rotation, contra-lateral pelvic drop, contra-lateral trunk lean, rearfoot eversion, tibial internal rotation, as well as forefoot dorsiflexion and abductionFindings: The patellofemoral pain group had significantly greater peak hip adduction and hip internal rotation. No differences in contra-lateral pelvic drop were found. A trend towards reduced contra-lateral trunk lean was found in the patellofemoral pain group. No significant differences were found in any of the rearfoot or forefoot variables but significantly greater shank internal rotation was found in the patellofemoral pain group.Interpretation: We found greater hip adduction, hip internal rotation and shank internal rotation in female runners with patellofemoral pain. We also found less contra-lateral trunk lean in the patellofemoral pain group. This may be a potential compensatory mechanism for the poor hip control seen. Rehabilitation programs that correct abnormal hip and shank kinematics are warranted in this population.

The effects of neuromuscular training on the gait patterns of ACL-deficient men and women - Corrected Proof

Stephanie L. Di Stasi, Lynn Snyder-Mackler — 2011-11-07

Abstract: Background: Anterior cruciate ligament rupture is the most common knee ligament injury sustained by active individuals, and the relative injury risk is sex-specific. Women not only demonstrate an increased risk for injury, but also a poorer response following ligament rupture. Perturbation training has shown positive results in healthy females, but gender-specific responses to training after injury have not been evaluated. The purpose of this investigation was to describe the effects of perturbation training on the gait characteristics of male and female non-copers.Methods: Biomechanical data were collected before and after training on 12 male and nine female non-copers using standard motion analysis techniques. Subjects walked at a consistent, self-selected speed over an embedded force plate. Data from both limbs were post-processed and analyzed using a mixed model analysis of variance and minimal clinically important differences to compare the limb behaviors of men and women.Findings: Prior to training, only women demonstrated significant hip joint excursion asymmetry (ES=1.03; P=0.009). Minimal clinically important difference values showed that the involved limb of the women had reduced hip and knee flexion angles and moments, truncated knee excursions, and increased hip excursions when compared to their own uninvolved limb and the limbs of the male non-copers. Following training, only knee extensor moment values exceeded the minimal clinically important differences in women.Interpretation: Female non-copers demonstrated unique movement strategies following injury and perturbation training. Women may be a meaningful subgroup of non-copers, and future investigations should consider the effects of gender in the outcomes of non-copers.

Kinematics and early migration in single-radius mobile- and fixed-bearing total knee prostheses - Corrected Proof

N. Wolterbeek, E.H. Garling, B.J. Mertens, R.G.H.H. Nelissen, E.R. Valstar — 2011-11-07

Abstract: Background: The mobile-bearing variant of a single-radius design is assumed to provide more freedom of motion compared to the fixed-bearing variant because the insert does not restrict the natural movements of the femoral component. This would reduce the contact stresses and wear which in turn may have a positive effect on the fixation of the prosthesis to the bone and thereby decreases the risk for loosening. The aim of this study was to evaluate early migration of the tibial component and kinematics of a mobile-bearing and fixed-bearing total knee prosthesis of the same single-radius design.Methods: Twenty Triathlon single-radius posterior-stabilized knee prostheses were implanted (9 mobile-bearing and 11 fixed-bearing). Fluoroscopy and roentgen stereophotogrammetric analysis (RSA) were performed 6 and 12months post-operatively.Findings: The 1year post-operative RSA results showed considerable early migrations in 3 out of 9 mobile-bearing patients and 1 out of 11 fixed-bearing patients. The range of knee flexion was the same for the mobile-bearing and fixed-bearing group. The mobile insert was following the femoral component during motion.Interpretation: Despite the mobile insert following the femoral component during motion, and therefore performing as intended, no kinematic advantages of the mobile-bearing total knee prosthesis were seen. The fixed-bearing knee performed as good as the mobile-bearing knee and maybe even slightly better based on less irregular kinematics and less early migrations.

The importance of pulsed lavage on interface temperature and ligament tension force in cemented unicompartmental knee arthroplasty - Corrected Proof

M. Clarius, J.B. Seeger, S. Jaeger, G. Mohr, R.G. Bitsch — 2011-11-03

Abstract: Background: Mechanical loosening is the most common cause of revision in unicompartmental knee arthroplasty. We determined the effect of bone lavage on tibial cement penetration and interface temperature with controlled ligament tension forces. We presumed pulsed lavage would allow increased cement penetration compared with syringe lavage.Methods: Cemented unicompartmental knee arthroplasty was performed in 12 pairs of fresh–frozen knees. Lavage was performed using pulsed lavage on one side (A) and syringe lavage on the other (B). Cement penetration pressure, interface temperature, and ligament tension forces were continuously monitored during the operation. Screened radiographs were taken and cement penetration under the tibial plateau was measured.Findings: The pulsed lavage group showed a mean cement penetration area of 187.24 (SD 36.37) mm², whereas 144.29 (SD 35.74) mm2 was measured in the group with syringe lavage. Cement penetration pressure was 13.29 (SD 8.69) kPa in Group A and 20.21 (SD 7.78) kPa in Group B. Maximum interface temperatures of 46.99°C were observed in Group A and 45.02°C in Group B.Interpretation: Our data showed pulsed lavage cleansing of the cancellous tibial bone substantially improved cement penetration compared with syringe lavage without reaching the temperature threshold for bone necrosis. We recommend the routine use of pulsed lavage to improve long-term fixation.

Lack of effect of moderate-duration static stretching on plantar flexor force production and series compliance - Corrected Proof

Dale Cannavan, David R. Coleman, Anthony J. Blazevich — 2011-11-02

Abstract: Background: The effects of an acute bout of moderate-duration static stretching on plantar flexor force production, series compliance of the muscle–tendon unit, and levels of neuromuscular activation were examined.Methods: Eighteen active individuals (9 men and 9 women) performed four 45-s static plantar flexor stretches and a time-matched control of no stretch (where subjects remained seated in the dynamometer for 4min with no stretch being performed). Measures of peak isometric moment, rate of force development, neuromuscular activation (interpolated twitch technique and electromyography), twitch force characteristics, passive moment during stretch, and tendon elongation during maximal voluntary contractions were taken before and after the stretching.Findings: Despite a significant stress–relaxation response during stretch (9.3%, P<0.01) there were no significant differences in peak isometric moment (P=0.35; effect size 0.13), rate of force development (P=0.93; effect size 0.01), neuromuscular activation (interpolated twitch: P=0.86; electromyography: P=0.09; effect size 0.02), or tendon elongation (P=0.61; effect size 0.07) after stretching. Twitch characteristics were also unchanged after stretching, although there was a reduction in the rate of twitch torque relaxation (RRt; P<0.01).Interpretation: The acute bout of moderate-duration static stretching did not impair the force generating capacity of the plantar flexors or negatively affect muscle–tendon mechanical properties. Static stretching may not always have detrimental consequences for force production. Thus, clinicians may be able to apply moderate-duration stretches to patients without risk of reducing muscular performance.

Estimating foot inertial parameters: A new regression approach - Corrected Proof

A. El Helou, J.M. Gracies, P. Decq, W. Skalli — 2011-10-28

Abstract: Background: Estimating the inertial parameters for the foot (mass, center of mass position and inertia tensor) is important for applications involving the ankle joint such as inverse dynamics or stiffness measurement techniques (e.g. Quick-release). Scaling equations relying on foot length and body mass are widely used. However, because of the complex foot geometry, such equations may represent an oversimplified solution. Our aim was to evaluate these approaches and propose a new method.Methods: Thirty-four right feet (17 Males, mean age and weight 30years, 75 kg; 17 Females, 32years, 61.5 kg) were reconstructed using a 3D surface scanner and used as geometrical references. Associated inertial parameters were calculated directly on each reference assuming a uniform density distribution and were compared to corresponding scaling and multiple regression estimates. Finally, an alternative method, based on multiple non-linear regressions, was proposed considering both foot length (L) and ankle width (W).Findings: Comparisons showed that reference mass and moments of inertia were greater than scaling predictions with mean difference up to 33 and 16% for mass and moments of inertia respectively. The maximum standard errors of estimate for scaled moments of inertia reached 26%. The alternative solution involving ankle width in the equations lowered the gap with reference data (8.7% max standard errors of estimate) for both genders.Interpretation: This strategy, requiring two simple and accessible measurements, may offer a better practicality/relevance compromise for clinical routine use, in regards to existing scaling and regression equations.

Investigation of hand muscle atrophy in stroke survivors - Corrected Proof

Kristen M. Triandafilou, Derek G. Kamper — 2011-10-28

Abstract: Background: Weakness is often profound in the contralesional hand after stroke. Relative contributions of various neural and mechanical mechanisms to this impairment, however, have not been quantified. In this study, the extent of one potential contributor, muscle atrophy, was noninvasively assessed in index finger musculature using ultrasonographic techniques.Methods: Twenty-five stroke survivors (45–65years old) with severe hand impairment resulting from a stroke occurring 2–4years prior participated, along with 10 age-matched control subjects. Muscle cross sectional area and thickness were geometrically measured from ultrasound images on both limbs of participants.Findings: Muscle size on the paretic limb of stroke survivors was smaller for all 7 hand muscles investigated. An average difference of 15% (SD 4) was seen for muscle cross sectional area and 11% (SD 2) for muscle thickness, while the difference between the dominant and non-dominant limbs for control subjects (6% (SD 2) and 1% (SD 4) for the muscle cross sectional area and muscle thickness, respectively) was not significant.Interpretation: Although muscle atrophy was detected in the paretic limb following stroke, it is not explanatory of the marked impairment in strength seen in this stroke population. However, other alterations in muscle morphology, such as fatty infiltrations and changes in fiber structure, may contribute to the emergent muscle weakness post-stroke.

Distal biceps tendon rupture: An in vitro study - Corrected Proof

2011-10-26

Abstract: Background: Options for repair of distal biceps tendon ruptures are well-described. However, scant data exist in the literature regarding failure strength of the native tendon. We hypothesize that a) the distal biceps tendon failure strength is sensitive to loading angle, and b) the failure strength is greater than what has been previously reported in the literature.Methods: 15 radii were potted in a simulated supine position, and the native tendon was pulled from the tuberosity at angles of 90, 60, and 30° of flexion (5 per group) relative to the long axis of the radius. The failure load and stiffness were recorded and compared.Findings: The native tendon's mean failure load tended to increase as flexion angle decreased. Due to the large variability in strength, mean failure loads of the 90° (mean 358 (SE 117N)), 60° (mean 617 (SE 141N)), and 30° (mean 762 (SE 130N)) groups were not statistically different from each other (P=0.12). The mean stiffness results for each group (mean 501 (SE 176N/mm), mean 763 (SE 226N/mm), and mean 756N (SE 179N/mm), respectively) were not significantly different from each other (P>0.6).Interpretation: The load to failure of the distal biceps tendon may be higher than what has previously been reported, and may be dependent on the elbow flexion angle. Though this difference may be attributed to the difference in methodology it should be taken into account during consideration of repair and rehabilitation.